Professional Provider Manual - Care Management

1 care ManagementThis section provides information on care Management programs available for your CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (CareFirst) the terms of the Participation Agreement, all providers are required to adhere to all policies and procedures contained in this Manual , as we make any procedural changes, in our ongoing efforts to improve our service to you, we will update the information in this section and notify you through email and BlueLink, our online Provider requirements of a member s health benefits vary and may differ from the general procedures outlined in this Manual . If you have questions regarding a member s eligibility, benefits or claims status information, we encourage you to use one of our self service channels; CareFirst Direct or CareFirst on Call.

2 Through these channels, simple questions can be answered quickly. Read and print the guidelines for Provider Self improvement (QI) programThe goal of the quality improvement (QI) program is to continuously improve the quality and safety of clinical care , including behavioral health care , and the quality of services provided to members within and across health care organizations, settings and levels of care . CareFirst strives to provide access to health care that meets the Institute of Medicine s aim of being safe, timely, effective, efficient, equitable and patient program goals and objectives1. Support and promote all aspects of the CareFirst Patient Centered Medical Home (PCMH) program and the Total care and Cost Improvement (TCCI) programs as a means to improve quality of care , safety, access, efficiency, coordination and Maintain a high quality network of providers and practitioners to meet the needs of the population we serve.

3 3. Implement methods, tracking, monitoring, and oversight processes for all TCCI programs to measure their value and impact for appropriate patients with complex health care All elements of the CareFirst TCCI program will be operating at targeted Establish collaborative partnerships to proactively engage clinicians, providers and community hospitals and organizations to implement interventions that address the identified (medical and behavioral) health and service needs of our membership throughout the entire continuum of care and those who are likely to improve desired health Deliver data and support to clinicians to promote evidence based clinical practice and informed referral choices and members to use their benefits to their Management7. Maintain a systematic process to continuously identify, measure, assess, monitor and improve the quality, safety and efficiency of clinical care (medical and behavioral health)

4 And quality of Assess the race, ethnicity, language, interpreters, cultural competency, gender identity and sexual orientation needs of our diverse populations while considering such diversity in the analysis of data and implementation of interventions to reduce health care disparities, improve network adequacy and improve cultural competency in materials and Monitor and oversee the performance of delegated Develop and maintain a high quality network of health care practitioners and providers who meet the needs and preferences of the membership by maintaining a systematic monitoring and evaluation Operate a QI program that is compliant with and responsive to federal, state, and local public health goals and requirements of plan sponsors, regulators and accrediting Provide insight based on SearchLight data to increase the knowledge base of the medical panels in the evaluation of their outcome Address health needs of all patients along the health care continuum, including those with complex health needs (advanced developmental, chronic physical and/or behavioral illness or complicated clinical situation).

5 14. Support quality improvement principles throughout the organization; acting as a resource in process improvement recognizes that large racial and ethnic health disparities exist and communities are becoming more diverse. Racial, ethnic and cultural background influence a member s view of health care and its results. CareFirst uses member race, ethnic and language data to find where disparities exist, and we use the information in quality improvement committeesCareFirst s multi disciplinary committees and teams work closely with community physicians to develop and implement the QI practitioners, including designated behavioral health care practitioners, provide input and feedback on quality improvement program activities through participation in the following committees.

6 CommitteePurposeQuality Improvement Advisory Committee (QIAC)A multi specialty committee of practitioners who advise the insurer about standards of medical and behavioral health careQuality Improvement Council (QIC)Evaluates the quality and safety of clinical and behavioral health care and the quality of services provided to membersCredentialing Advisory Committee (CAC)Reviews the credentials of practitioners and other providers applying for initial or continued participation in the planCare Management Committee (CMC) Monitors and analyzes the care Management program and promotes efficient use of health care resources by members and practitionersDelegation Oversight (DOC)Monitors and analyzes performance of all delegates performing functions on behalf of CareFirstCare ManagementPerformance dataA status of performance and evaluation of meeting goals of the QI program can be found at CareFirst and CareFirst BlueChoice retain the right, at their discretion, to use all Provider and/or practitioner performance data for QI activities including but not limited to, activities to increase the quality and efficiency to members (or employer groups), public reporting to consumers and member cost Committee for Quality Assurance (NCQA)All CareFirst s health maintenance organization (HMO) and preferred Provider organization (PPO) products are accredited.

7 Accreditation is awarded to plans that meet NCQA s rigorous requirements for consumer protection and quality is an independent, not for profit organization dedicated to assessing and reporting on the quality of managed care Plans. NCQA s Accreditation standards are publicly reported in five categories: Access and service do health plan members have access to the care and service they need? Qualified providers does the health plan assess each doctor s qualifications and what health plan members say about its providers? Staying healthy does the health plan help members maintain good health and detect illness early? Getting better how well does the health plan care for members when they become sick? Living with illness how well does the health plan care for members when they have chronic conditions?

8 Patient Centered Medical Home (PCMH) programCareFirst s PCMH program is designed to provide primary care providers (physician or nurse practitioner) with a more complete view of their patients needs and services they receive from other providers to better manage their individual risks, keep them in better health and produce better outcomes. The program requires greater Provider patient engagement and it meaningfully compensates providers for that part of CareFirst s PCMH program, the chronic care coordination program provides coordination of care for patients with multiple chronic illnesses and is carried out according to care plans developed under the direction of the PCP. While care plans may result from a case Management or HTC episode, they also originate from a review of the trailing 12 months of health care use by an attributed member who is identified as likely to benefit from a care plan.

9 care coordination for these patients is carried out through the local care coordinator (LCC) who is assigned to each Provider /practice within a panel. The LCC assists the PCP in coordinating all elements of the patient s health care , ensuring all action steps in the plan are followed up and carried out. CareFirst provides online tailored care plan templates that are suitable for the needs of members with various chronic diseases ( , diabetes, asthma, COPD, coronary artery disease, congestive heart failure, hypertension, childhood obesity), or for members with condition clusters ( , a member with diabetes, obesity and congestive heart failure; or a member with coronary artery disease with myocardial infarction and hypertension). The vast majority of patients for whom care plans are most appropriate have multiple morbidities.

10 Each care plan template is based on the latest evidence based clinical care guidelines for the condition or PCMH program has a significant upside for the Provider , for the patient and CareFirst as a steward of its members health care dollars. For more specific program information, including eligibility and how to get started, visit ManagementDisease Management programsCareFirst offers disease Management programs designed to reinforce and support the physician s plan of care . All programs are voluntary and uses claims data to identify members with the following chronic conditions who are eligible for disease Management : asthma, diabetes, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), heart failure, chronic low back pain, osteoarthritis, atrial fibrillation, irritable bowel syndrome (IBS), and fibromyalgia.